Dear Editor, Porphyrias refer to a group of rare inherited metabolic disorders resulting from reduced activity of any of the enzymes in the heme production pathway. Accumulation of the porphyrin precursors is associated with diverse pathologic changes, and become the basis for diagnostic tests (1). Acute intermittent porphyria (AIP) is themostcommon type of porphyrias, and seizures are typically a manifestation of acute attacks. AIP can also be associated with idiopathic or symptomatic epilepsy (2). Since many antiepileptic drugs can worsen the patient’s condition or disease attacks, knowledge of the effects of AEDs is important. Trying to treat seizuresmayunmaskAIP, which has been previously hidden. Due to the broad spectrum of clinical symptoms, porphyry diagnosis depends on a strong clinical suspicion (3). We present here a child with the final diagnosis of porphyria.

Introduction: We describe a patient without a history of cardiovascular diseases as an example of Wellens’ syndrome (WS). Case Report: A 65-year-old man presented to emergency department due to intermittent chest pain. Physical examination and chest x-ray were unremarkable. Electrocardiogram (ECG) showed biphasic Twave in precordial leads V1-V4. Primary cardiac serum biomarkers including high-sensitive cardiac troponin T (hs-cTnT) and CK-MB were slightly elevated, that further assessment did not show any increases; while ECG recorded during a pain period revealed T-wave pseudo-normalization. The patient underwent coronary angiography that revealed a proximal left anterior descending artery lesion. Conclusion: WS is a diagnostic and management challenge and serial ECG evaluation is still essential for a possible acute coronary syndrome. Having knowledge of all subtle features of this syndrome, could avoid improper discharge of high-risk patients. Definitely, accurate risk stratification, and prompting these patients to an early coronary angiogram and treatment are mandatory to avoid development of a massive anterior myocardial infarction.

Aims: Aspiration of stomach contents is a serious side effect in patients with a feeding tube which can be prevented otherwise may lead to death. There have been disputes over the safest feeding method. Therefore, this study seeks to identify the chance of occurrence of respiratory aspiration in two tube feeding methods of intermittent bolus and intermittent drip bag.Methods: In this quasi-experimental study, 72 patients in ICU and trauma ward who were fed through tube, investigating contextual variables and using gradual method, were divided into two groups of intermittent bolus and intermittent drip bag method and both groups were independently fed for 3 days. After that, both groups were surveyed and compared based on the level of aspiration occurrence. To collect the data, personal information, nutrition, and respiration form as well as form of information about the two feeding methods in the studied units were utilized. The studied units were selected among Training and Treatment Centers in Rasht in 2010. To analyze the data, descriptive and inferential statistics and SPSS16 software were used.Results: The respiratory aspiration occurrence level in intermittent bolus tube feeding methods was 5.6% whereas this amount in intermittent drip bag method was zero. Fisher exact test revealed that there was no significant relationship between these two groups (p=0.47).Conclusion: As there was no significant relationship in respiratory aspiration between the two groups, it concluded that intermittent bolus method can still be mentioned in books as a standard method which can decrease the risk of aspiration if it is used properly.

Leech infestation may cause serious complications like airway obstruction, severe respiratory distress, hemoptysis, hematemesis or rectal bleeding. One such case presenting with vomiting and intermittent gastrointestinal bleeding is described below.A previously healthy 9-year-old boy referred to the emergency department of Tabriz children's hospital with a 5-day history of nausea and vomiting of bloody material. He reported 3 intermittent bloody vomits without abdominal pain. His mother stated that the patient had 38°C fever. The patient's symptoms had continued for 3 days, and then he was brought to us. Upon arrival, he had nausea and vomited with bloody content and coughed. His father said that approximately 3 days before onset of symptoms he went on a camping trip in Northwest Iran, where he bathed in a pond. He stated also that the drinking water there was not filtered.

Purpose: To evaluate the role of orthoptic treatments in the management of intermittent exotropia.Methods: In a retrospective study, clinical records of patients diagnosed with intermittent exotropia were reviewed. Patients with basic, convergence insufficiency (CI) and divergence excess (DE) types of intermittent exotropia who underwent orthoptic treatments were enrolled. Office treatments included prism exercises and pencil push-ups, and home exercises included pencil push-ups, 3D tests and dominant eye occlusion. Clinical evaluation of symptoms, binocular orthoptic status and maximum angle of deviation was done before treatment and at 8 weeks after the beginning of the treatment and at the time of last examination.Results: Seventy four patients with a mean age of 18.4±12.2 years and mean follow-up of 13.5±10.1 weeks were included in the study. Forty three (58.1%) patients had a basic type of exodeviation, 22 (29.7%) had a CI type of exodeviation and 9 (12%) had a DE type of exodeviation. The treatment was successful in 88.3% of patients in basic type, all patients in CI type and 88.8% in DE group. Success rate was not significantly different between the three groups (P=0.25). Strabismus surgery was performed in one patient in basic type and one in DE group due to the lack of improvement.Conclusion: Orthoptic treatment seems to be effective in reducing symptoms and improving signs of intermittent exotropia.